— 藥理與非經腸給藥 · HARD · MCQ —
一位服用華法林（Warfarin）的病人 INR 為 5.5。護理師應優先採取什麼行動？
A client on warfarin therapy has an INR of 5.5. What is the nurse's priority action?
- ANotify the physician to discuss holding or adjusting the dose✓ 正解通知醫師討論暫停或調整劑量
- BPrepare to administer vitamin K subcutaneously準備皮下注射維生素K
- CAdminister the next dose of warfarin as scheduled按原定計畫給予下一劑華法林
- DInstruct the client to eat more leafy green vegetables指示客戶多吃葉菜類蔬菜
— Explanation · 中文詳解 —
華法林（Warfarin）抗凝血治療需密切監測 INR。正常目標值通常為 2.0-3.0，若 INR 高達 5.5，代表抗凝血效果過強，病人處於嚴重的出血風險（Bleeding risk）中。護理師的首要行動是保護病人安全，暫停給藥並立刻通知醫師討論劑量調整或是否需要給予維生素 K（Vitamin K）拮抗劑。自行決定給藥或教導飲食調整無法解決當前的嚴重凝血異常。
An INR of 5.5 indicates excessive anticoagulation and a high risk of bleeding, requiring immediate medical evaluation. The nurse's priority is to notify the physician to determine if the warfarin dose should be held or adjusted, rather than administering further doses or making independent decisions about vitamin K.